Patterns in Medicine


We came across a booklet that could be a good example for the kind of studies by the envisioned Thinkibility University. At its West Wing, scientists dissect the basic thinking patterns in a scientific discipline.

Siddhartha Mukherjee was asking himself: If there is a science of medicine, then science has laws. Physics has laws. Chemistry has laws. Biology has laws.

The simple question was: If that’s the case, then what are the laws of medicine? These were not meant to be universal commandments. These were meant to be explorations about principles that might hold true about medicine today and about medicine in the future. That was the framework for this book.

Law One : A strong intuition is much more powerful than a weak test.

Law Two: “Normals” teach us rules; “outliers” teach us laws

Law Three: For every perfect medical experiment, there is a perfect human bias

Watch or read here an interview with him about the book. You could also read the Ted book: The Laws of Medicine Field – Notes from an Uncertain Science

For us, Gijs and Asa, it is not the description of the laws of a scientific discipline that interests us – how interesting they are by itself but the possibility they give to escape from it. Once spelled out, laws are just vehicles to set up new approaches.

In short, at the West Wing of the Thinkibility University, they are thinking laterally about science.


We have earlier written about patterns in science and possible escapes from them in the following blogposts:

Our next post about the topic “Patterns in Science” will be about Patterns in Law. Could it be that in Western law assumptions are hidden that hinders us in modern times?

Not to miss?  Follow Thinkibility. The blog about Thinking, Creativity, Innovation and Design.


Key Performance (mis) Indicators


Key Performance Indicators are meant to keep an organisation on track. By measuring the performance over time, you are able to look at deviations and to take measures. As Wikipedia defines it: A  key performance indicator (KPI) is a type of performance measurement. An organization may use KPIs to evaluate its success, or to evaluate the success of a particular activity in which it is engaged. Sometimes success is defined in terms of making progress toward strategic goals, but often success is simply the repeated, periodic achievement of some level of operational goal (e.g. zero defects, 10/10 customer satisfaction, etc.).

The concept behind Key Performance Indicators is to build a feedback loop between input and output. Its working principle does not differ from a thermostat, which senses the temperature of a system so that the system’s temperature is maintained near a desired set-point.


In order to get not market driven organisations more efficient the adage “The numbers tell the tale”has become fashion among governments, institutions and not-for-profit companies. There are several metrics or key performance indicators.

However, Key Performance Indicators can also lead to perverse incentives and unintended consequences as a result of employees working to the specific measurements at the expense of the actual quality or value of their work. In the social sciencesunintended consequences (sometimes unanticipated consequences or unforeseen consequences) are outcomes that are not the ones intended by a purposeful action. Perverse incentives are a type of unintended consequence. A perverse incentive is an incentive that has an unintended and undesirable result which is contrary to the interests of the incentive makers.

There are a lot of examples of bad designed Key Performance Indicators. We came across, but not exhaustive:

  • Police officers get a predetermined quota of fines to give out. The unintended effect of this KPI that the police organisation will be focused on easy to obtain files, f.i. traffic fines instead of fighting serious crime;
  • An organisation involved in handling objections has a KPI for the amount of rejected complaints. Imagine how employees will approach complaints. . .
  • It is generally accepted that the progress of students is evaluated by tests. However, student tests assess only a small part of needed knowledge, skills and attitude of students. Also, often the purpose of the test, timely warning of learning difficulties and study delays, dilutes to “a (missed) ticket to the next hurdle”;
  • An agency of child protection is responsible for placing abused or emotional neglected children in foster parents and child care institutions. It is very logic to design a KPI: like the number of placed children. If this performance is coupled to the financing of the agency, it can easily lead  to placing children out of their home, against sound indications that there is no need for or against parents objections;
  • It is complete reasonable to expect higher efficiency and experience of surgeons as a hospital performs at least 30 knee surgery or angioplasty a year. However, such a KPI can lead to more instead of less knee surgery and angioplasty, an example of a perverse effect contrary to what was originally intended (an intended solution makes a problem worse);
  •  The selling of mortgages as an end in itself, even to people who could no pay the interest, led to the bank crisis in 2008. Another example of a negative, unexpected detriment occurring in addition to the desired effect of the policy to motivate sellers to do better their best.
  • To increase the efficiency of university studies universities are judged on the number of successful students per year. It is now tempting to reduce the requirements for passing exams.
  • In order to increase the efficiency of General Practitioners many assurance companies allow for not more than ten minutes consults by patients. This KPI leads to far more referrals to medical specialists because GP’s have not much time to carefully investigate the medical complaints. This is an example of a counterproductive KPI: it is more of an “obstacle” than a help in the achieving of a productive project or an objective;
  • Crews of warships run annual series of nautical and operational exercises. Through a complex multi-factor analysis, a KPI is derived: Operational Employ-ability. Members of Parliaments asked questions when the KPI decreased to 10%, as a warship was actually deployed in a crisis;
  • Notorious are budgets: the setting of expenditure levels for each of an organization’s functions. It expresses strategic plans of business units, organizations, activities or events in measurable terms. However, such budget tends to be exhausted at the end of the year, because organizational units realise that they will be shortened in budget for next year, because last year they needed not the full budget. So, as an example, in many towns you can observe that every five to ten years the same streets and squares are completely overhauled without any need but in order to use the full budget.

Many Key Performance Indicators have unintended effects. They function as rules for behavior. Key performance Indicators are designed to notice need for adjustments of the course of an organisation. However, more often than not, they are invitations to cheat, by employees but equally by companies and institutions,  especially when financial consequences are attached to the KPI.

Whenever designing or encountering a Key Performance Indication, be warned!


unintended consequences

For more examples of perverse incentives, see here. For examples of unintended consequences see here.

To built up your Thinkibility skills, imagine your are the director of a hospice. You have set a thinking task: how to improve the occupancy (KPI) of the hospice. Then check your answers with How Dying Became A Multibillion-Dollar Industry.



Uncertainty – Thinkibility Nibble


Often when we search for information we want to be certain that the results are true or we assume that the results are true and certain. But scientific uncertainty is part of scientific research. Since we do not know everything, research continues and it is constantly changing. New ideas and pieces of information is added.

  • Researchers have to decide “how much of the picture is known and how confident we can all be that their findings tell us what’s happening or what’s going to happen. This is uncertainty.“ (Making Sense of Uncertainty)

When a scientist describes the uncertain part of the research, we should be pleased rather than discourage an open discussion about the uncertainty. Climate science, disease modelling, and weather forecasting all have a degree of uncertainty. This is not a deficiency and it certainly does not mean that anything can be true. We may expect scientific research to be true and certain and it is this expectation that is the problem. Yet we still need to make decisions based upon the uncertain results and by explaining and estimating the uncertainty, we have a higher degree of confidence regarding what is known and unknown.

Ignoring results simply on the basis that they are uncertain prevents us from making decisions and taking actions. If we expect certain results, we will never make changes to prevent climate changes or develop new drugs. Complex systems, such as ecological systems or the human body, are not easy to understand and we may never have certain knowledge about what will happen. Identifying area of uncertainty should be part of any research map.

Scientists are developing research maps to help them deal with data deluge. Organising discoveries is vital to prevent duplicating experiments and to ensure that key discoveries are noted. A map makes it easy to see what areas that have been covered and the impact of the results to future studies. Neuroscientists have developed maps that show findings in molecular and cellular cognition and an app has been developed to help researchers to expand and interact with the map. The maps work more or less as an online query, where you can see as much of the maps as you like to. The map can be used to explore what information that is missing and it highlights areas that may be interesting to study.

Uncertainty is often used to dismiss results and undermine the evidence. We need to explore in what ways  our actions  is or is not affected by the uncertainty. When we make decisions for checking for fake passports at the airport, we need a higher level of certainty that it will work as compared to when we discuss policies to reduce the number of road accidents.

While uncertainty is not a barrier to taking action, there are  situations where we should not focus on the uncertainty of the research. In some cases, the aim is to test and see how well an observation can explain a certain theory that we have about the world. There is also uncertainty in the data that is collected and this is different from an uncertainty in the conclusions that is drawn. Different scientists can reach different conclusions when they examine the same set of data.

Uncertainty maps:

  • Identify areas of uncertainty
  • Possible factors that influence the uncertainty
  • The scale of the uncertainty
  • Ways to deal with the uncertainty
  • What does the uncertainty mean for a decision? Do we need to  make another decision?
  • Are there some other pieces of information that has different uncertainty?

Above all –  be suspicious when someone says that something is certain!

Photo:”Book Of Knowledge” by digitalart

Remedies Against Groupthink

Groupthink Consequences
Groupthink is described historically by the myth of the Cassandra syndrome. This myth describes a prediction or warning that goes unheeded with serious consequences. The term comes from the story about Cassandra, who was raped by the senior adviser to her father at court. To defend against accusations, she was personally discredited. So Cassandra’s special talent for predicting future unknowns was also discredited, with disastrous results of war and destruction.

Groupthink manifests itself in statements such as,“This could simply not be true. It cannot happen here.” Examples are in government corruption, partiality of judges, sexual harassment of a worker by a superior, pedophilia by priests, price fixing between corporations, doctor’s scams, or fraudulent investment funds.

If no one believes you despite clear indications or evidence that your claims are valid, it may lead to significant physical and psychological issues, such as schizophrenia and paranoia. This claim of insanity awaits whistle blowers. And you can safely assume that in administrative and social elite situations, by definition there is groupthink.

Remedies against Groupthink
There are a number of answers for groupthink. In formal debate, you may appoint a Devil’s Advocate.  To build in considerations about public safety, legislature can subsidize a critical social movement, i.e. environmentalism. Prosecutors and police may set up contradiction teams to prepare alternative hypotheses about suspects.

Better Solutions Need Better Ideas
A problem is that these remedies are within the pattern of the standard approach of improvement through the criticism of logical reasoning. A hypothesis is proposed and then it must be proved that the statement is incorrect; or a statement can be declared impossible to disprove, so it cannot be a valid beginning hypothesis. The qualification of truth is characterized by attack and defend, win or lose. Hegel rightly observes that this was the dominant condition of exceptional Western progress.

Taken to extremes, we have seen that using conflict to determine truth has drawbacks inherent in Cassandra’s syndrome. Criticism, debate and argument prevents the creative design of solutions.

Six Thinking Hats method
One answers to overcoming the limitations of traditional dialectic thinking is the Six Thinking Hats method, designed by Edward de Bono. It describes the advantages of parallel thinking.  The Six Thinking Hats method was developed around 1982. The Six Thinking Hats has been used worldwide with success by many diverse groups –  large corporations and small primary schools, by government juries and activists.

Photo:  Crowd Thinking by fotographic1980,

The Role of Criticism

Find the Truth
Someone once asked me “How can we increase people’s willingness to accept criticism and enhance their ability to find the truth?”

Personally, I do not believe that human nature can be changed. For example, the idea that another banking crisis can be prevented by people calling for less greed, does not make sense to me. There must be a definite consequence or a benefit for change to happen. Are laws, rules, procedures, and rituals that were designed to reduce the avoidance of criticism and encourage the search for truth working as intended?

Criticism has a function
First, criticism has its own purpose and function. It prevents people saying stupid or untrue things. It is the possibility of criticism that makes people careful and forces them to use logical thinking. So it is good that people are sensitive to criticism and strive to avoid it.

But there are disadvantages to avoiding criticism, given a culture where people derive their self-esteem from being able to think intelligently and independently. This is especially true in the United States and Northern Europe. Both cultures owe their prosperity to the presence of criticism. The development of technology, medicine, and economy would not have been possible without criticism of existing concepts and ideas. Hegel rightly observes that dialectical thought was the dominant reasons for exceptional Western progress. That is why the ability to review, test, and correct thinking is fully institutionalized in the educational systems and professions of these cultures. A drive to avoid criticism is what causes both social and legislated rules to exist.

Better Thinking
The ability to correct reasoning has become a dominant part of defining how to think, commonly in the term “critical thinking.” It is supposed to be built into the “rigorousness” of college level courses. There is an assumption that college level study will automatically lead to better thinking. In these cultures, a person’s status and ability to think is primarily evidenced by their education. The admonition, “To get a higher status job, students should do their best in school and especially in college,” has become a self-fulfilling prophecy.  As a consequence, all well-paid staff positions requiring thinking have a prerequisite of higher education credentials. To apply for a well-paying job, a person at least needs to have a college degree because this implies they been qualified for thinking.

However, it appears that educational systems have gradually evolved to produce professors. If a person has only a master’s degree, they can be considered to be a failed professor.

Finally, regardless of the rather sloppy assumption that years of scientific study will automatically lead to real better thinking; the ability to correct reasoning has become a dominant part of the self. However, as an alternative, you might also derive a sense of the self from being able to paint.

It is interesting that most people are not concerned about the fact that they have moderate skills in painting, sports, or in raising children. These skills do not determine their self-image as much as the ability to think.

The answer to,”what do you do for a living?” is the most common determination of a person’s cultural identity. Someone could just as well derive a sense of their identity from being a painter, excelling at sports or being a parent. It is interesting that most people are not concerned about the fact that they may have inadequate skills in those areas. If you want to pursue study to become a recognized musician or artist, you still at least need to have a high school diploma to qualify for admission to a music conservatory or art college, as well as having completed college prerequisites before taking studio classes in your discipline, regardless of your previous experience.

In these cultures, none of these skills or situations determine socially recognized value as much as the ability to think.

Thinking and self-image
There are many compelling reasons to avoid criticism; avoiding personal insult, avoiding consequence from disagreeing with those in authority, social pressure to conform, or avoiding the assignment of blame or extra work. To avoid criticizing others about their thinking seems to avoid many repercussions and “keep the peace.” Even though anyone can clearly note “the Emperor has no clothes,” appearances of agreement can easily become a higher priority than being truthful, reasonable or offering ideas for improvements.

Because the primary role of criticism is to eliminate, it leads to uncertainty, which in itself can be uncomfortable. Uncertainty reveals there is a risk being taken by answering unknowns. Uncertain situations where answers need to be found that are coupled with a time pressure can exceed a tolerance limit for finding the best answers. This situation may justify extreme reactions, especially when having to presuppose social opinion. A phenomenon of second-guessing an extreme version of conformity is likely to emerge as a coping strategy. Groups will tend to decide on a priority need to follow badly designed solutions based on insecurities, fears, or radical reactions, in spite of clear signals of incorrect reasoning.

Disastrous in practice
One can see the disastrous consequences of groupthink in situations where  under time pressure decisions are made, such as in police investigations that are broadly in the social spotlight, the management of football clubs  or political parties which are under  criticism of public figures or in company’s boardrooms where the losses are piling up.

Photo:  By 143is (Own work) [CC-BY-3.0 (], via Wikimedia Commons